Citation NR: 9613165 Decision Date: 05/08/96 Archive Date: 05/21/96 DOCKET NO. 94-31 973 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Columbia, South Carolina THE ISSUE Entitlement to an increased rating for post traumatic stress disorder (PTSD), currently evaluated as 30 percent disabling. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD Debbie A. Riffe, Associate Counsel INTRODUCTION The veteran had active service from July 1966 to June 1968. In an August 1992 rating decision of the Columbia, South Carolina Regional Office (RO), service connection was granted for post traumatic stress disorder (PTSD), and a 30 percent evaluation was assigned effective from June 1992. This appeal arises from a February 1994 rating decision of the RO, which confirmed the 30 percent evaluation for PTSD. In November 1995, the veteran appeared and testified at a Travel Board hearing which was conducted by C.W. Symanski, who is the member of the Board of Veterans’ Appeals (Board) responsible for making a determination in this case. CONTENTIONS OF APPELLANT ON APPEAL The veteran contends that the RO erred when it determined that his ability to earn a living and make and maintain relationships was not sufficiently impaired to warrant an increased rating. He claims that his PTSD symptoms warrant a rating increase to 70 percent. The veteran asserts that since 1982, he has been unable to keep a job. He claims that he avoids social interactions, except on a superficial level, and is unable to trust anyone. He states that he has had two failed marriages, two five-year relationships, and is presently involved in another volatile relationship. He has lost contact with his family. The veteran claims that his life continues to be extremely affected by his Vietnam experiences, and that he has nightmares, job “languish,” no friends, alienation from family, and volatile intimate relationships. DECISION OF THE BOARD The Board, in accordance with the provisions of 38 U.S.C.A. § 7104 (West 1991 & Supp. 1995), has reviewed and considered all of the evidence and material of record in the veteran's claims file. Based on its review of the relevant evidence in this matter, and for the following reasons and bases, it is the decision of the Board that the evidence supports a 70 percent rating for PTSD. FINDINGS OF FACT 1. All relevant evidence necessary for an equitable disposition of the veteran’s appeal has been obtained by the RO. 2. The veteran’s service connected PTSD is productive of severe social and industrial impairment. CONCLUSION OF LAW The veteran’s PTSD is 70 percent disabling, according to regulatory criteria. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. Part 4, including §§ 4.1, 4.2, 4.7, 4.10, 4.129, 4.130, Code 9411 (1995). REASONS AND BASES FOR FINDINGS AND CONCLUSION The Board is satisfied that all relevant facts have been properly developed, and that no further development is required to comply with the duty to assist the appellant mandated by 38 U.S.C.A. § 5107(a). By rating action of August 1992, the veteran was granted service connection for PTSD, and assigned a 30 percent evaluation under the Diagnostic Code 9411 of the VA’s Schedule for Rating Disabilities (38 C.F.R. Part 4), effective from June 1992. The action was based on service medical records, VA outpatient treatment records, and a VA examination, which verified the veteran’s participation in combat operations in Vietnam and showed a current diagnosis of and treatment for PTSD. In September 1992, the veteran submitted a letter indicating that he had not been able to hold a job for over ten years. He stated that he has had two wives and numerous girlfriends, and that he found himself isolated and alone, even in a crowd. In February 1994, VA outpatient records of one-to-one treatment, dated from July 1993 to January 1994, were submitted. On a July 1993 notation, the veteran reported nightmares of being chased and flashbacks. It was noted that the veteran had a severe problem with alienation from people. The assessment was PTSD, Vietnam, considerable to severe. On a September 1993 record, the veteran reported continuing problems with PTSD symptoms, including frequent social withdrawal, depressed anxiety, sleep disturbance, nightmares, and more intrusive thoughts of Vietnam. The assessment was PTSD, Vietnam, chronic, considerable to severe. An October 1993 record indicates that the veteran avoided television, newspapers, and social contact with people for days. The assessment was PTSD, Vietnam, chronic, severe industrial and social impairment. On a December 1993 record, the veteran reported that his nightmares and intrusive thoughts were worse and that he was unable to keep his business going. The assessment was PTSD, considerable to severe. A January 1994 record indicates that the veteran reported continuing problems with PTSD symptoms. He had intrusive thoughts, was more depressed, and slept less. The assessment was PTSD, Vietnam, chronic, severe industrial and social impairment. On a March 1994 psychiatric evaluation report from Silvia Bloch, M.D., the veteran reported having nightmares and intrusive memories of Vietnam for years. He had two failed marriages and was socially isolated. The veteran reported that he self-medicated with alcohol and drugs. It was noted that during the interview, the veteran was visibly anxious, tense, and had sweaty palms. The veteran reported that he currently could not get along with his girlfriend, and that he tried odd jobs such as insurance sales. He reported that he got depressed but did not stay depressed and had never been suicidal. On mental status examination, the veteran was alert and oriented times three, and his mood was noted to be anxious depressive. His affect was constricted and his thoughts were coherent. The veteran was not suicidal or homicidal, but impulsive and aware of his potential for impulsive acting out. He had fair insight and judgment and appeared to be of high average intelligence. His cognition and concentration were impaired. The diagnoses included PTSD, Vietnam related with significant comorbidity. Dr. Bloch noted that the veteran tended to overplay his symptoms and that his PTSD required ongoing psychological treatment and perhaps psychiatric medication management for concomitant symptoms of depression and anxiety. In May 1994, the veteran submitted with his substantive appeal a computer printout report of his Social Security employment record, dated from 1978 to 1992. More than two dozen employers are listed on the report. In May 1994, the veteran’s representative submitted VA form 646, accompanied by an undated report from a VA counseling psychologist. The report indicates that the veteran’s PTSD was seen as materially contributing to the impairment of his employability. It was noted that the veteran’s productivity had been sporadic in spite of his above average ability, college training, and experience, and that he currently worked in insurance sales. The report indicates that an employment handicap existed, which was not serious at the present time, and that an assessment of the veteran’s current situation suggested that the achievement of a vocational goal under Chapter 31 was reasonably feasible at this time. On VA examination in September 1994, the veteran reported having held three or four jobs this year, working as a satellite television salesman, mortgage salesman, and other sales jobs. The veteran complained that he had trouble getting along with authority and people, which was manifested by difficulty in getting close to people and having a bad temper. He reported nightmares two or three times a week, in which he was chased by people he killed in Vietnam, and flashbacks which were greater than they were ten years ago. The veteran had a consistent problem with alcohol. He indicated that he tried to keep himself busy all day, running an office or working out; otherwise, he drank heavily and became depressed. On mental status examination, the veteran was pleasant and cooperative, and he appeared somewhat anxious, especially when talking about Vietnam or his symptoms. He denied a thinking disorder and hallucinations. There was no evidence of delusions, and his judgment and insight were good. The impression included PTSD (Axis I). The examiner noted that PTSD clearly interfered with his relationships; that he had almost no friends at the time; that he could not get along with relatives; that his symptoms affected his relationships and ability to hold a job; that he self-medicated with alcohol; that he was considered moderately disabled from PTSD; and that he was capable of managing his own funds. At a Travel Board hearing in November 1995, the veteran’s representative indicated that the veteran had about 30 different jobs over the past 10 to 12 years and that the medical evidence of record showed that the veteran’s PTSD was more severe than his present 30 percent evaluation. The veteran testified that he had nightmares, difficulty sleeping, and a short temper; that he was not employed by anyone because he worked as a independent contractor, “kind of” in the mortgage business; that the number of hours he worked varied; that his PTSD symptoms affected his abilities to do any type of work because he did not like authority; that following service he worked himself up to a corporate personnel manager, a position he held for 10 years until 1981 or 1982; that since 1982 he had not worked a year for any one company; that he currently experienced “generic” nightmares and sleeplessness, and was impatient with people and got angry; that he had flashbacks which manifested “in the form of anger and anxiety and a sort of a lashing out type of thing of whoever is around me”; that his thoughts periodically went back to his days in the service; that he had a good relationship with his children; that he was fairly isolated; and that his PTSD had “ruined” him economically. At the Travel Board hearing, the veteran submitted a letter from VA clinical psychologist, Colin Doyle, Ph.D., dated in October 1995. The letter indicated that he had evaluated and treated the veteran since July 1993, and that it was his opinion that the veteran was severely disabled due to his PTSD. It was noted that the veteran had approximately 10 different jobs over the last two years and had not been successful at any position, despite his intelligence and serious attempts. He noted that the veteran’s PTSD symptoms of severe anxiety, intrusive thoughts, poor sleep, nightmares, flashbacks, anger, and irritability resulted in significant cognitive impairment, which made his attention span, comprehension, and short-term memory unreliable and unpredictable. Under the applicable criteria, disability evaluations are determined by the application of a schedule of ratings which is based on average impairment of earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. Separate diagnostic codes identify the various disabilities. The Department of Veterans Affairs (VA) has a duty to acknowledge and consider all regulations which are potentially applicable through the assertions and issues raised in the record, and to explain the reasons and bases for its conclusions. Schafrath v. Derwinski, 1 Vet.App. 589 (1991). These regulations include, but are not limited to, 38 C.F.R. §§ 4.1 and 4.2. Also, 38 C.F.R. § 4.10 provides that, in cases of functional impairment, evaluations must be based upon lack of usefulness of the affected part or systems, and medical examiners must furnish, in addition to the etiological, anatomical, pathological, laboratory and prognostic data required for ordinary medical classification, full description of the effects of the disability upon the person’s ordinary activity. These requirements for evaluation of the complete medical history of the claimant’s condition operate to protect claimants against adverse decisions based upon a single, incomplete, or inaccurate report, and to enable the VA to make a more precise evaluation of the level of the disability and of any changes in the condition. Schafrath, 1 Vet.App. at 594. When there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. A 50 percent evaluation for PTSD requires that the ability to establish or maintain effective or favorable relationships with people is considerably impaired and that by reason of psychoneurotic symptoms the reliability, flexibility, and efficiency levels are so reduced as to result in considerable industrial impairment. A 70 percent evaluation for PTSD requires that the ability to establish and maintain effective or favorable relationships with people is severely impaired and that psychoneurotic symptoms are of such severity and persistence that there is severe impairment in the ability to obtain or retain employment. A 100 percent evaluation requires that attitudes of all contacts except the most intimate are so adversely affected as to result in virtual isolation in the community; that there are totally incapacitating psychoneurotic symptoms bordering on gross repudiation of reality with disturbed thought or behavioral processes associated with almost all daily activities such as fantasy, confusion, panic, and explosions of aggressive energy resulting in profound retreat from mature behavior; and that the individual must be demonstrably unable to obtain or retain employment. 38 C.F.R. Part 4, Diagnostic Code 9411. 38 C.F.R. §§ 4.129 and 4.130 provide that social and industrial inadaptability are basic criteria for rating mental disorders. Social integration is one of the best evidences of mental health and reflects the ability to establish (together with the desire to establish) healthy and effective interpersonal relationships. However, in evaluating impairment, social inadaptability is to be evaluated only as it affects industrial adaptability. 38 C.F.R. § 4.129. In evaluating psychiatric disabilities, the severity of disability is based upon actual symptomatology as it affects social and industrial adaptability. Two of the most important determinants of disability are time lost from gainful work and decrease in work efficiency. An emotionally sick veteran with a good work record must not be underevaluated, nor must his condition be overevaluated on the basis of a poor work record not supported by the psychiatric disability picture. 38 C.F.R. § 4.130. In this case, the evidence shows that the veteran continues to be treated for PTSD symptoms. The veteran has problems in maintaining relationships with others, as evidenced by his failed marriages and broken relationships with girlfriends, and in retaining a job, as evidenced by his sporadic and inconsistent work history. It was opined several times in VA outpatient treatment records from July 1993 to January 1994 that the veteran’s PTSD was considerable to severe in degree. The undated VA report from a counseling psychologist submitted in May 1994 indicated that a employment handicap existed for the veteran, although not a very serious one. In the September 1994 VA examination, the veteran was considered to be moderately disabled from PTSD. A VA clinical psychologist opined in October 1995 that the veteran was severely disabled due to his PTSD. At the hearing in November 1995, it was argued that the veteran could not hold a steady job, as evidenced by his spotty work history, and that PTSD affected his ability to work in any capacity. The veteran testified that he was isolated socially and had problems relating with authority. His work record with numerous job changes in recent years tends to support his claim. Clearly, there are varying opinions as to the severity of the veteran’s psychiatric disability ranging from moderate to severe. In view of the spotty work record, the veteran’s testimony and the assessments of the psychologists who are seeing the veteran for treatment, it would appear that the evidence is at least in equipoise as to whether the psychiatric disability is productive of considerable or severe industrial inadaptability. Giving the benefit of the doubt to the veteran, the Board concludes that the veteran’s PTSD is productive of severe social and industrial impairment under Code 9411. Thus, a 70 percent evaluation is warranted. It is noted that the veteran is engaged in employment currently, working as an independent contractor apparently selling insurance. Under such circumstances, not more than 70 percent would be in order either under the schedular standards or under the provisions of 38 C.F.R. § 4.16 (c). ORDER An increased rating to 70 percent for PTSD is granted, subject to the applicable criteria governing the payment of monetary benefits. C.W. SYMANSKI Member, Board of Veterans' Appeals The Board of Veterans' Appeals Administrative Procedures Improvement Act, Pub. L. No. 103-271, § 6, 108 Stat. 740, 741 (1994), permits a proceeding instituted before the Board to be assigned to an individual member of the Board for a determination. This proceeding has been assigned to an individual member of the Board. NOTICE OF APPELLATE RIGHTS: Under 38 U.S.C.A. § 7266 (West 1991 & Supp. 1995), a decision of the Board of Veterans' Appeals granting less than the complete benefit, or benefits, sought on appeal is appealable to the United States Court of Veterans Appeals within 120 days from the date of mailing of notice of the decision, provided that a Notice of Disagreement concerning an issue which was before the Board was filed with the agency of original jurisdiction on or after November 18, 1988. Veterans' Judicial Review Act, Pub. L. No. 100-687, § 402, 102 Stat. 4105, 4122 (1988). The date which appears on the face of this decision constitutes the date of mailing and the copy of this decision which you have received is your notice of the action taken on your appeal by the Board of Veterans' Appeals. - 2 -